New ESC Guidelines on Acute Myocardial Infarction in patients presenting with ST-segment elevation (STEMI)
S. Brugaletta reviews the new ESC Guidelines on the Management of STEMI
Within the four guidelines released at the ESC Congress 2017, the STEMI guidelines may probably represent one of the most interesting for our community. Many of the changes in recommendations were already expected by many of us, whereas others are important to see and to digest.
Some expected updates
We were for example awaiting something new on access site and type of stent to be implanted and indeed, radial access and DES use have been upgraded to class I. Looking back at the 40 year journey of interventional cardiology, many years have passed to see both these recommendations as class I. For DES, in particular, we are far away from the thrombosis storm of ESC 2006 in Barcelona.
Another expected change is about thrombus aspiration: European guidelines are now in line with American guidelines, downgrading routine thrombus aspiration to class III with the maximum level A of evidence. Use of thrombus aspiration is restricted as bailout in certain cases.
An interesting point is also represented by the downgrading of bivalirudin use from I to IIa. This came even before the negative bivalirudin results of the VALIDATE-SWEDEHEART trial presented at this ESC congress and it will for sure generate much discussion in the next months between European and American cardiologists.
What's new: antiplatelet agents, revascularization strategy, elimination of "Door-to-Balloon" and MINOCA
Important points of these guidelines are about antiplatelet agents: for the first time we find cangrelor and long-term use of Ticagrelor up to 36 months (both as IIb indication). Cangrelor represents a new entry and future trials are needed to understand its specific value, especially taking into account that it is still not available in all European countries. For long-term use of Ticagrelor, many trials are currently on going to understand which kind of antiplatelet agent to use and for how long. For the time being and according to the available data, extension of DAPT beyond 1 year (up to 3 years) in the form of aspirin plus ticagrelor 60mg b.i.d. may be considered in patients who have tolerated DAPT without a bleeding complication and having one additional risk factor for ischaemic events.
An important role is also given to revascularization strategy, in particular complete revascularization is upgraded to IIa and routine deferred stenting is indicated as class III. As the optimal timing of revascularization (immediate vs. staged) has not been adequately investigated, no recommendation in favour of immediate vs. staged multivessel PCI was formulated.
We also see the elimination of “Door-to-Balloon” time: strategy clock starts at the time of “STEMI diagnosis” and not at the time of first medical contact. The reason behind this choice is probably the intention to have something easy to understand, but we should not forget the importance of the time between first medical contact and STEMI diagnosis, which in many countries still represent a problem, due to patient or EMS delay.
We have also a new chapter dedicated to MINOCA (Myocardial infarction with no obstructive coronary artery disease), which currently represents 1-14% of total myocardial infarctions. The guidelines in particular describe how to rule out its diagnosis, but it is lacking a part about a suggested treatment, which in many cases is based on expert reviews.
A new chapter on quality indicators & quality of health care
Last but not least the new chapter dedicated to quality indicators, pointing out the major attention from cardiologists to the quality of the health care provided. There is indeed a gap between optimal guideline-based treatment and actual care of STEMI patients. In order to reduce this gap, it is important to measure established quality indicators to audit practice and improve outcomes in real life. For these reasons, use of well-defined and validated quality indicators to measure and improve STEMI care is recommended. Assessment of quality of care was sometimes performed locally at hospital or regional level and it is important to see that it is now proposed directly from European STEMI guidelines. It would be great to use these quality of care indicators at European level to compare different countries and to further improve STEMI treatment within Europe.